ENS 57176

v t e ENS Event
19:26 Jun 14, 2024
Title	Dose Misadministration
Event Description	The following information was provided by the Oregon Department of Health Radiation Protection (the Department) via email: During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT. The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee." Oregon Event Report ID Number: OR-24-0030 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 57176 +/-
Where
Oregon Health &Amp; Sciences University Portland, Oregon (NRC Region 4)
License number:	ORE-90013
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+67.65 h2.819 days <br />0.403 weeks <br />0.0927 months <br />)
Opened:	Daryl Leon 15:05 Jun 17, 2024
NRC Officer:	Tenisha Meadows
Last Updated:	Jun 17, 2024
57176 - NRC Website
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